Vearey et al.

BMC Public Health (2019) 19:340

https://doi.org/10.1186/s12889-019-6674-8

CORRESPONDENCE Open Access

Urban health in Africa: a critical global

public health priority
Jo Vearey1, Isaac Luginaah2, Ng’weina Francis Magitta3, Dativa J. Shilla4 and Tolu Oni5,6,7*

Abstract
The African continent is predicted to be home to over half of the expected global population growth between
2015 and 2050, highlighting the importance of addressing population health in Africa for improving public health
globally. By 2050, nearly 60% of the population of the continent is expected to be living in urban areas and 35–
40% of children and adolescents globally are projected to be living in Africa. Urgent attention is therefore required
to respond to this population growth - particularly in the context of an increasingly urban and young population.
To this end, the Research Initiative for Cities Health and Equity in Africa (RICHE Africa) Network aims to support the
development of evidence to inform policy and programming to improve urban health across the continent. This
paper highlights the importance of action in the African continent for achieving global public health targets.
Specifically, we argue that a focus on urban health in Africa is urgently required in order to support progress on the
Sustainable Development Goals (SDGs) and other global and regional public health targets, including Universal
Health Coverage (UHC), the new Urban Agenda, and the African Union’s Agenda 2063. Action on urban public
health in Africa is critical for achieving global public health targets. Four key research and training priorities for
improving urban health in Africa, are outlined: (1) increase intersectoral urban health literacy; (2) apply a healthy
urban governance and systems approach; (3) develop a participatory and collaborative urban health planning
process; and, (4) produce a new generation of urban health scholars and practitioners. We argue that acting on key
priorities in urban health is critical for improving health for all and ensuring that we ‘leave no-one behind’ when
working to achieve these regional and global agendas to improve health and wellbeing.
Keywords: Urban health, Africa, Sustainable development goals, Universal health coverage, Agenda 2063, African
union, New urban agenda, Social determinants of urban health

The Research Initiative for Cities Health and Equity in development plan [4]. We outline four key research and
Africa (RICHE Africa) Network aims to support improve- training priorities for improving urban health in Africa,
ments in urban health across the continent. The RICHE that will ensure we ‘leave no-one behind’ when working to
Africa Network is made up of both early career and estab- achieve these goals.
lished researchers working to support evidence-informed
urban public health policy and planning processes in
Africa. In this brief paper, we argue that a focus on urban The importance of Africa for global public health
health in Africa is required to support progress on the Between 2015 and 2050, over half of the expected global
Sustainable Development Goals (SDGs) [1] and other population growth will be in Africa [5], highlighting the
global health targets, including efforts to achieve Universal importance of addressing population health on this con-
Health Coverage (UHC) [2] the Habitat III New Urban tinent for improving global public health. This increase
Agenda (NUA) [3] and the African Union’s Agenda 2063 in population growth in Africa is characterised by two
distinct features. Firstly, while Africa is currently the
* Correspondence: tolullah.oni@mrc-epid.cam.ac.uk least urbanised region of the world, it represents the
5
School of Public Health and Family Medicine, University of Cape Town, fastest urbanising continent, with 56% of the population
Faculty of Health Sciences, Room 4.41, Entrance 5, Falmouth Building, Cape of the African continent projected to be living in urban
Town, South Africa
6
Stellenbosch Institute for Advanced Study, Stellenbosch, South Africa areas by 2050 [6]. Secondly, this population growth is
Full list of author information is available at the end of the article characterised by a demographic youth bulge with 35–
© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Vearey et al. BMC Public Health (2019) 19:340
40% of children and adolescents globally projected to be
living in Africa by 2050 [7]. These features represent an
opportunity for improving health in the urban setting.
Urbanisation can result in an “urban advantage” with
improved access to healthcare services, education and
employment opportunities, and strengthened social con-
nections (compared to their rural counterparts), while
the youth demographic dividend represents an oppor-
tunity for economic growth through a growing skilled
workforce. However, this potential is as yet unharnessed
with increasing intra-urban inequities - evidenced by the
high proportion of African urban residents, including
those migrating into cities, living under conditions of
informality, such as unsafe human settlements, and poor
access to services that increase vulnerability to poor
physical, mental and social health - resulting in an
“urban penalty” [8]. This penalty is further exacerbated
by high rates of unemployment and high-risk health
behaviours among young people. This picture has
become increasingly complex in the African context,
with the rise of chronic non-communicable diseases
(NCDs) – such as diabetes, hypertension and heart
disease - affecting both non-poor and poor alike [9] and
a rising prevalence of infectious/NCD multimorbidity in
increasingly younger age groups [10].
A focus on urban health in Africa
Cities are, therefore, critical spaces for action to achieve
the SDGs, UHC, and NUA in Africa and, as a result, glo-
bally: both in terms of the numbers and demographics
of people living in urban areas now and in the future,
and as a result of increasing levels of urban health
inequities. Furthermore, the first goal set out by the
African Union in the Agenda 2063 development plan [4]
highlight the need to focus on inclusive growth and sus-
tainable development, through ensuring a high standard
of living, and quality of life, sound health and well-being.
This aspiration recognizes cities as important hubs of
cultural and economic activities, but also as sources of
exposures that determine health such as the nature of
the food system and exposure to high sugar and salt
foods; the quality of housing and contribution to social
cohesion, contributors to stress and exposure to noise,
air, and water pollution [11].
The RICHE Africa Network is working to develop a
common research and training agenda that aims to gener-
ate empiric evidence that presents options for improving
the health and wellbeing of urban residents across the
continent. Emerging out of a meeting of the International
Council of Science’s Urban Health and Wellbeing scien-
tific committee and a Future Earth Knowledge Network
meeting on Urban Health in Xiamen, China in December
2017, the RICHE Africa Network has identified four key
research and training priorities for improving urban health
Page 2 of 4
towards achieving the SDGs in Africa [1]: increase inter-
sectoral urban health literacy [2]; apply a healthy urban
governance and systems approach [3]; develop a participa-
tory and collaborative urban health planning process; and
[4], produce a new generation of urban health scholars
and practitioners.
Urban health priorities to achieve global and
regional sustainable development goals in Africa
Increase intersectoral urban health literacy
To address urban health in Africa we need to improve
urban health literacy across multiple sectors and at mul-
tiple levels, inclusive of public, private and civil society
actors. Urban health is more than meeting the health
needs of people living in cities. It is, in itself, an
approach that recognises the physical, social and eco-
nomic urban environments as determinants of health
and of health equity. Driven by a public health and social
justice agenda, an urban health approach recognises that
cities are inherently unjust spaces typified by inequality
and inequity, and the resultant intra-urban disparities in
health. The complexity of African cities needs to be
understood, by citizens and policymakers alike, from a
Social Determinants of Urban Health (SDUH) [12] per-
spective, that will allow for investigation and identifica-
tion of the interlinked multi-level and multi-sectoral
determinants of urban health (exposures) and the path-
ways that connect them to health outcomes (systems),
with the objective of improving equity in urban health
[8, 10]. Achieving this objective will require partnerships
with sectors and organisations across public policy, pri-
vate, and civil society actors, who are well positioned to
“move the needle” on these issues. There is therefore a
need for research into the knowledge and attitudes of
key stakeholders across these sectors, in order to inform
the development of appropriate strategies to improve
health and SDUH literacy. Such interventions should
target children and youth in the general population in
order to bolster prevention efforts at the individual,
community, and structural levels, and to empower com-
munities to apply an SDUH and rights-based lens to
better advocate for improved living and working condi-
tions in the city.
Apply a healthy urban governance and systems approach
The rapid growth rate of many African cities results in
existing urban governance systems struggling to meet
demand, with reactive - rather than proactive - city plan-
ning being implemented. This governance approach
does not adequately consider the SDUH and health out-
come implications of interventions and results in further
deepening experiences of deprivation and inequity.
These deprivations affect the ability of some residents –
particularly those residing on the physical and social
Vearey et al. BMC Public Health (2019) 19:340
periphery of the city - to thrive [13]. An SDUH lens
facilitates the identification and analysis of the multiple
factors, such as diet, physical activity, natural and built
environments affecting equity in health, and calls for a
multilevel approach - beyond the individual - to develop
interventions to address these foundational health deter-
minants. This includes addressing commercial determi-
nants of health, and developing improved public policy
that is aligned for health and sustainable development.
Key to this is the role of governance – “the institutions
and processes through which societies manage the
course of events” [14]. Governance is about the ways in
which multiple actors work together: the state; civil soci-
ety; academia; the private sector; and, community-based
organisations. In the context of cities, evidence indicates
that improved urban governance is required to inform
sustainable and healthy urban planning [14]. Such
healthy urban governance requires improved under-
standing of city dynamics – urban growth, migration
and mobility, resource mobilisation and use, informality,
ageing populations - and engagement with social, phys-
ical, environmental, and economic security, all of which
are key, interlinked determinants of urban health.
Unpacking and understanding the complexity of
health in African cities, and the ways in which govern-
ance structures affect equity in health, requires research
to explore and understand the relationships between
exposure(s) and the distribution(s) of health outcome(s)
as well as the inter-relationships between city, provincial,
and national governments. Health inequities in the city
are the outcome of multiple system failures, requiring a
systems approach to research and action [8, 15]. Critical
to this is the availability of quality integrated, intersec-
toral and longitudinal data that can be disaggregated and
used for the exploration of multi-causality pathways.
Such evidence can be used to inform policy development
and prioritisation, as well as to evaluate the health
(equity) impact of intersectoral urban interventions.
Develop a participatory and collaborative urban health
planning process
We need to move beyond existing, sectoral approaches to
health in urban settings and develop contextually relevant
city health plans. Key here is the need for multiple and
collective actions to improve global health; action on Goal
3 – to ensure healthy lives and promote wellbeing for all
at all ages - has been identified as central to achieving
progress across all SDGs [16]. This requires a focus on the
ways that local government interfaces with the city as a
service provider, and the modes of city planning and gov-
ernance. Local-level researchers, practitioners and city
managers should be involved in the collective and partici-
patory development of urban health plans [17] to support
a systems approach for engagement and action between
Page 3 of 4
sectors [9, 15]. Such plans should include the identifica-
tion of short, medium, and long-term goals, with a clear
guiding framework for deliverable health outcomes.
Ideally, these plans and the associated activities and out-
comes should be integrated into existing performance
management systems at the local government level across
health and non-health sectors. Participatory approaches
should crucially involve the public; this recognises the
potential to mobilise young people to act both as citizen
scientists - applying innovative approaches to collection of
SDUH data in the city - and as engaged members of their
community who can provide informed input into pro-
posed urban health planning processes.
Produce a new generation of urban health scholars and
practitioners
We need to develop improved undergraduate and post-
graduate training in order to produce a new generation
of African urban health scholars and practitioners who
are literate across sectors and disciplines, and have
specialised skills in systems thinking in order to conduct
implementation and transdisciplinary research. Critically,
these scholars and practitioners need to be able to act as
interlocutors – catalysts – between diverse urban gov-
ernance actors, and be able to meaningfully lead engage-
ment with different stakeholders on why urban health
matters, and why often challenging cross-sectoral collab-
oration should be made a priority in their respective
mandates.
Moving forward, we call on the global health commu-
nity, and especially African governments to consider the
African urban health agenda. In order to make any gains
on global and regional sustainable development and
health agenda – including the SDGs, UHC, and Agenda
2063, systems approaches to improving urban health
and addressing urban justice in Africa should be
prioritized.
Abbreviations
NCDs: Non-communicable diseases; RICHE: Research Initiative for Cities
Health and Equity; SDGs: Sustainable Development Goals; SDUH: Social
Determinants of Urban Health; UHC: Universal Health Coverage
Acknowledgements
Members of the Research Initiative for Cities Health and Equity in Africa
(RICHE Africa) Network; the International Council of Science’s Urban Health
and Wellbeing scientific committee; and participants of the Future Earth
Knowledge Network meeting on Urban Health held in Xiamen, China in
December 2017.
Funding
JV is supported by a Wellcome Trust Investigator Award. This funding
supported the writing of the manuscript. TO is supported by an Iso Lomso
Fellowship of the Stellenbosch Institute for Advanced Study (STIAS) and an
Oppenheimer Memorial Trust sabbatical study award. This work was in part
supported by a grant to TO from the LIRA 2030 Africa Programme, which is
implemented by the International Council for Science (ICSU) in partnership
with the Network of African Science Academies (NASAC) and the
International Social Science Council (ISSC), with support from the Swedish
Vearey et al. BMC Public Health (2019) 19:340 Page 4 of 4

International Development Cooperation Agency (Sida). This funding
supported the writing of the manuscript. The funders had no role in the
design or writing of the manuscript.
Availability of data and materials
Not applicable.
Authors’ contributions
JV wrote the first version of the manuscript based on discussions held at a
meeting in Xiamen, China in December 2017 in which all authors
participated. All authors reviewed and contributed to the final manuscript.
All authors read and approved the final manuscript.
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Publisher’s Note
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published maps and institutional affiliations.
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Author details
1
African Centre for Migration & Society, University of the Witwatersrand,
Johannesburg, South Africa. 2Department of Geography, The University of
Western Ontario, London, Ontario, Canada. 3Department of Biochemistry,
Mbeya College of Health and Allied Sciences, University of Dar es Salaam,
Mbeya, Tanzania. 4Department of Environmental Chemistry, Dar es Salaam
University College of Education, Dar es Salaam, Tanzania. 5School of Public
Health and Family Medicine, University of Cape Town, Faculty of Health
Sciences, Room 4.41, Entrance 5, Falmouth Building, Cape Town, South
Africa. 6Stellenbosch Institute for Advanced Study, Stellenbosch, South Africa.
7
MRC Epidemiology Unit, University of Cambridge, Cambridge, UK.

Received: 25 February 2018 Accepted: 18 March 2019

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